Biliary sludge.

Biliary sludge was first described with the advent of ultrasonography in the 1970s. It is defined as a mixture of particulate matter and bile that occurs when solutes in bile precipitate. Its composition varies, but cholesterol monohydrate crystals, calcium bilirubinate, and other calcium salts are the most common components. The clinical course of biliary sludge varies, and complete resolution, a waxing and waning course, and progression to gallstones are all possible outcomes. Biliary sludge may cause complications, including biliary colic, acute pancreatitis, and acute cholecystitis. Clinical conditions and events associated with the formation of biliary sludge include rapid weight loss, pregnancy, ceftriaxone therapy, octreotide therapy, and bone marrow or solid organ transplantation. Sludge may be diagnosed on ultrasonography or bile microscopy, and the optimal diagnostic method depends on the clinical setting. This paper proposes a protocol for the microscopic diagnosis of sludge. There are no proven methods for the prevention of sludge formation, even in high-risk patients, and patients should not be routinely monitored for the development of sludge. Asymptomatic patients with sludge can be managed expectantly. If patients with sludge develop symptoms or complications, cholecystectomy should be considered as the definitive therapy. Further studies of the pathogenesis, natural history, and clinical associations of biliary sludge will be essential to our understanding of gallstones and other biliary tract abnormalities.

Chemical composition of gallbladder sludge in patients after marrow transplantation.

OBJECTIVES: Gallbladder sludge develops in approximately 70% of patients after bone marrow transplantation (BMT). Sludge often develops in these patients without known predisposing factors, such as fasting or narcotic use. In this study, we examined the chemical composition of sludge in BMT patients. METHODS: Gallbladder content samples from 15 patients were obtained at autopsy. Presence or absence of sludge was determined by examination of gallbladder contents. Sludge samples were examined with direct and polarizing microscopy and assayed for cholesterol, bilirubin, and calcium content and for the presence of a calcium-binding protein. RESULTS: On microscopic examination, cholesterol monohydrate crystals were almost completely absent. Calcium bilirubinate crystals were present in large amounts in all samples. Calcium-ceftriaxone crystals were found in two patients who had received ceftriaxone. A large proportion of the sludge (84.6%) was found to be "unmeasurable residue." Of this part, 5-30% was accounted for by a calcium-binding protein. CONCLUSIONS: We conclude that gallbladder sludge in patients after marrow transplantation consists primarily of "unmeasurable residue," calcium bilirubinate, and a calcium-binding protein. Cholesterol crystals are almost absent. We conclude that formation of gallbladder sludge in these patients could serve as a model for studying the pathogenesis of pigment gallstones.

Evaluation of a non-breath-hold MR cholangiography technique.

PURPOSE: To evaluate prospectively a non-breath-hold magnetic resonance (MR) cholangiographic technique. MATERIALS AND METHODS: Twenty-nine non-breath-hold, heavily T2-weighted, turbo spin-echo MR cholangiograms were obtained in 28 patients and compared with 28 direct cholangiographic studies in 24 patients. RESULTS: MR cholangiography showed the intrahepatic ducts (IHDs) within the peripheral third of the liver and within the four hepatic segments in 100% of cases with dilated ducts. IHDs were seen in the peripheral third in 82% of cases with nondilated ducts and within the four hepatic segments in 91%. The extrahepatic duct (EHD), dilated and nondilated, was visualized in 90% of cases. Filling defects were identified in the EHD in 71% of cases and in the gallbladder in 100%. All obstructions were identified and their site and character accurately shown in most cases. The presence of IHD dilatation was accurately shown, and estimates of EHD and main pancreatic duct caliber correlated closely with those of direct cholangiography. CONCLUSION: Non-breath-hold MR cholangiography is a reliable method for depiction of the biliary system.